WEEKLY STANDARD MINIVAN (SMV) VEHICLE INSPECTION CHECKLIST (One driver per form)

Driver’s Signature:______Week of : ______

Driver’s Name: ______

Manufacturer: ______Model Year:______Last six digits of vin#______Agency Vehicle # ____

______Beginning Mileage ______Ending Mileage

Manufacturer’s Recommended Service Interval______miles:

______Maintenance due within 500 miles

______Maintenance past due

______Mechanical failure, describe on back of form

Inspect and check each item below:______

S / M / T / W / T / F / S / S / M / T / W / T / F / S
Vehicle Exterior / Electrical Continued
Signs of leaks under vehicle / Emergency flashers
Tires inflated / Horn
Windows and mirrors clean / Windshield wipers
Doors open/close / Brakes
Under hood / CHECKED BY ANOTHER PERSON OR BY MIRROR
Oil level / Brake Lights
Windshield washer fluid / Backup lights
Hoses, dripping fluids, cracked or leaking / Rear left turn signal
Belts not frayed or cracked / Rear right turn signal
VEHICLE INTERIOR
Clean interior / SAFETY EQUIPMENT
Floor free of hazards / Reflective triangles or flares
Seat belts in good condition / First aid kit
Adjust mirrors / Fire extinguisher
Check brakes / Biohazard kit
Heater (Spring-Winter-Fall) / Vehicle accident package
A/C (Spring-Summer-Fall) / Vehicle insurance card
Defrosting system / Seatbelt cutter
Adequate Fuel
Any warning lights on / Check only if agency requires daily check
Two-way communication / Coolant level
Doors locking / Brake fluid
Brakes / Transmission fluid
Power steering fluid
Electrical / Corrosion on battery
Turn signals:
Front Left
Front right
High beams
Low beams
Back up alarm, if equipped

Indicate any physical damage to the exterior of body. Additional information may be provided on back